ORIGINAL ARTICLE

COMPLICATIONS ASSOCIATED WITH IVANISSEVICH

PROCEDURE FOR VARICOCELE TREATMENT
Fazal Ahmed, Waseem Muhammad, Qazi Tahir Uddin
Department of Surgery, KMU Institute of Medical Sciences, Kohat, Pakistan
ABSTRACT
Background: Ivanissevich procedure is commonly practiced in district hospitals for the management of varicocele.
However, the complications associated with this procedure are considered to be higher as compared to other
procedures such as Paloma and laproscopy. The aim of this study was to find out the frequency of complications
associated with Ivanissevich procedure for varicocele treatment.
Material & Methods: This descriptive study was performed at Department of Surgery, DHQ Hospital, Kohat,
from June 2011 to June 2013. Total 125 patients were studied. All these patients were having grade II varicocele.
Complications were observed over the follow-up period of 6 months.
Results: The age range of patients was 15 to 42 years with mean of 26.9 years. Ninety percent of these patients
had grade II left sided varicocele. Regarding complications 5(4%) patients had postoperative hematoma /hy-
drocele formation, 12(10%) had scrotal edema that settled within a week, 20(16%) patients had recurrence and
2(1.6%) patients had testicular atrophy.
Conclusion: Ivanissevich procedure has a high complication rate and alternate procedures with low complication
rates like Paloma and laprorscopic varicocelectomy should be considered as the treatment options.
KEY WORDS: Varicocele; Complications; Testis; Hematoma; Scrotal hydrocele; Atrophy.
This article may be cited as: Ahmed F, Muhammad W, Uddin QT. Complications associated with Ivanissevich
procedure for varicocele treatment. Gomal J Med Sci 2014; 12:165-7.

INTRODUCTION retroperitoneal ligation of the testicular veins. Incision

is 2-3 cm in length lateral to or below the umbilicus
Varicocele is found approximately in 10-15% of 2-3 cm laterally. Also laparoscopic retroperitoneal
the population and its incidence is higher in infertile approach is used. Nowadays embolisation of the
population (30-45%). 95% of the varicoceles are on diseased vessels is also on the cards.6,7
the left side and the difference in venous drainage of
the two sides accounts for this left-sided dominence.1 The aim of this study was to find out the fre-
It is mostly idiopathic however it can occur secondary quency of complications associated with Ivanissev-
to renal cell carcinoma when it invades renal vein.2,3 ich procedure.
Varicocele is also regarded as one of the surgically
treatable causes of male infertility. MATERIAL AND METHODS
The basic principle in its management is cutting A total of 125 patients were selected for the
the venous continuity of the spermatic vessels. This study which was conducted in the Surgical Depart-
is done surgically by following different approaches ment of Divisional Headquarters Hospital KDA Kohat
such as Low ligation i.e. Ivanissevich procedure, from June 2011 to June 2013.
high ligation (Paloma procedure) and laproscopic The patients were admitted from out Patient
varicocelectomy.2 Low ligation (Ivanissevich) entails department of the hospital and all the baseline in-
2-3 cm inguinal crease incision followed by dis- vestigations were performed in the hospital. In order
section of the engorged vessels and ligation with to rule out other pathologies like carcinoma kidneys,
suture followed by transection of these vessels.4,5 ultrasonography of the abdomen, pelvis and scrotum
High Ligation (Paloma) on other hand comprises were included in the screening. All the patients se-
Corresponding Author: lected were having grade II varicocele and operation
Dr. Fazal Ahmed was performed by consultant in charge to eliminate
Assistant Professor Surgery operative bias. Complications in patients were ob-
KMU Institute of Medical Sciences served over the follow-up period of 6 months. All the
Kohat, Pakistan patients were followed fortnightly for one month and
E-mail: [email protected]

Gomal Journal of Medical Sciences July-September 2014, Vol. 12, No. 3 165
Fazal Ahmed, et al.

then monthly for 6 months. Results were analyzed medical services.7

using SPSS version 17.
The etiology of varicocele is not known. The
RESULTS venous dilatation is due is to absent valves, increase
in venous pressure in long spermatic vessels drain-
A total of 125 patients were studied. Age range ing at right angle into the renal vein, compression
of patients was 15 to 42 years with mean age of 26.9 of the left renal vein, increased pressure in the iliac
years. Majority of patients were in the 3rd decade of vein transmitted to the pampiniform plexus through
life i.e. 52.7% (66 patients) while 29.16% (36 patients) ductus deferens vein which drains into internal iliac
and 19.77% (23 patients) were in 4th and 2nd decades vein. Appearance of varicocele in middle aged men
respectively. (Table 1) should raise the suspicion of renal cell carcinoma.8
Depending on the size, varicocele is divided into
Out of 125 patients 104 (83.2%) had grade
three grades; being palpable with valsalva manoeu-
II left-sided varicocele while 18 (14.4%) patients
vre (grade I), palpable without valsalva manoeuvre
had bilateral grade II varicocele and 3 (2.4%) had
(grade II) and visible (grade III). The diagnosis of
right-sided varicocele.
varicocele is mainly clinical.9 In subclinical cases
Postoperative complications were noted and doppler ultrasonography, contact scrotal thermog-
it was found that 5 (4%) patients had postoperative raphy, blood pooling radioisotope angiography and
hematoma /hydrocele formation, 12 (10%) patients spermatic venography may be helpful. An ultrasound
had scrotal edema that settled within one week, 20 of testis helps to assess the size of testes.
(16%) patients had recurrence in the form of per-
The indication of surgery in cases of varico-
sistent dilated veins and hanging down testes and
celectomy is mere its presence. Macleod reported
2 (1.6%) patients had testicular atrophy. (Table 2)
that 90% of the patients have decreased sperm
Table 1: Age distribution of study patients motility and 65% has decreased sperm count. Main
(n=125). indications for surgery are bilateral palpable or
symptomatic varicoceles, abnormal sperm counts,
Age (in years) Number Percentage smaller testes on affected side and cosmoses.
11-20 23 19.77% There are a number of surgical procedures
21-30 36 52.7% available for treatment of varicocele.10,11 These are
low ligation (Ivanessivich), high ligation (Paloma),
31-40 66 29.16% laparoscopic and transcutaneous balloon emboli-
zation. Each procedure has its merits and demerits.
Table 2: Post-operative complications after vari-
Principle however is same for all i.e. interruption in ec-
cocele surgery by Ivanissevich procedure.
static vein that make up varicocele with preservation
Complications Frequency Percentage of testicular artery preventing testicular atrophy.12,13
Hence the preferable surgical approach should be
Hematoma /Hydro- 5 4% the one that is easy to perform and has less com-
cele plications. Out of all the above stated procedures
Recurrence 20 16% Paloma procedure and laproscopic varicocelectomy
is nowadays recommended. Owing to their easy
Edema 12 10%
procedure and minimum complications.15-17
Testicular Atrophy 2 1.6%
In our study, the mean age of the patients
DISCUSSION was 26.6 years. Other studies also showed that the
disease was most prevalent in third decade of life
Varicocele is found in 10% of individuals most (52.7%).15
commonly in younger age groups. Most commonly
left side is affected. Our results are consistent with It was also found that complications with low
others studies regarding the side of occurrence of ligation (Ivanessivich) were high. This was evident in
varicocele. Reported incidence of left-sided varico- other studies namely Bechara et al and Shamsa et
cele is 85.6%, 0.4% right sided and 14% bilateral.6 al.8,9 Recurrence rate in other studies was 16% and
11%.14,15 Similar results (16%) were obtained in our
Varicocele presents at early adolescence, rare- research.
ly detected individuals are younger than 10 years.
In our study mean age was 26.6 years. Most of the Postoperative hydrocele is a major problem
patients were in 3rd decade of life (52.77%) whereas after most inguinal procedures and same were in
remaining were distributed in 4th and 2nd decade of our study (3%).16,17 This was also supported by the
life as 29.16% and 16.66% respectively. The late re- aforementioned studies. Hence our results were
porting was related to ignorance and lack of regular comparable to available international data.

Gomal Journal of Medical Sciences July-September 2014, Vol. 12, No. 3 166
 Complications associated with Ivanissevich procedure for varicocele

CONCLUSION roscopic varicocelectomies in terms of operative

time sperm parameters, and complications. Urol
It was concluded that low ligation (Ivanessivich) J 2009; 6:170-5.
is the procedure associated with high rate of com-
plications. Hence other procedures like high ligation 10. Cayan S, Shavakhabov S, Kadioğlu A. Treatment
of palpable varicocele in infertile men: a me-
(Paloma) and laproscopic varicocelectomy should
ta-analysis to define the best technique. J Androl
be considered as the treatment options. 2009; 30:33-40.
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varicocelectomy. Vascular 2009; 17:129-36. Authors declare no conflict of interest.
GRANT SUPPORT AND FINANCIAL DISCLOSURE
9. Shamsa A, Mohammadi L, Abolbashari M, Shak-
None declared.
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